eMedicine Specialties > Emergency Medicine > Neurology

Cavernous Sinus Thrombosis: Differential Diagnoses & Workup

Author: Rahul Sharma, MD, MBA, Instructor in Medicine, Weill Medical College of Cornell University; Consulting Staff, Department of Emergency Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center
Coauthor(s): Edward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University
Contributor Information and Disclosures

Updated: Jul 18, 2008

Differential Diagnoses

Cellulitis
Periorbital Infections
Epidural and Subdural Infections
Sinusitis
Epidural Hematoma
Subarachnoid Hemorrhage
Glaucoma, Acute Angle-Closure
Subdural Hematoma
Orbital Infections

Other Problems to Be Considered

Carotid artery aneurysm or fistula
Exophthalmic goiter
Orbital neoplasm

Workup

Laboratory Studies

  • Cavernous sinus thrombosis (CST) is a clinical diagnosis and lab studies are seldom specific. Most patients exhibit a polymorphonuclear leukocytosis, often marked with a shift toward immature forms. Examination of the cerebrospinal fluid is consistent with either a parameningeal inflammation or frank meningitis. Blood culture results generally are positive for the offending organism.

Imaging Studies

  • Historically, a number of techniques have been used to image CST, including plain sinus radiography, carotid angiography, and orbital venography. In current practice, computed tomography (CT) scan or magnetic resonance imaging (MRI) with contrast is the modality of choice to confirm the diagnosis of CST and to differentiate it from alternatives such as orbital cellulitis, which may have a similar clinical presentation.
  • MRI with MR venogram (MRV) is the preferred imaging choice as the MRV will show the absence of venous flow in the affected cavernous sinus. 
  • On noncontrast CT, thrombosis of the cavernous sinus can be appreciated as increased density. The introduction of intravenous contrast can reveal filling defects within the cavernous sinus as well as thickening of the superior ophthalmic vein. Nevertheless, CT scan findings may be subtle, and a negative CT scan cannot rule out CST reliably when the clinical suspicion is high.
  • Carotid angiography can demonstrate narrowing or obstruction of the intercavernous segment of the carotid artery. MRI and CT scan can also show this narrowing and/or obstruction of the carotid artery.

Procedures

  • Lumbar puncture may be helpful in distinguishing CST from more localized processes (eg, sinusitis, orbital cellulitis). Lumbar puncture reveals inflammatory cells in approximately 75% of cases.

More on Cavernous Sinus Thrombosis

Overview: Cavernous Sinus Thrombosis
Differential Diagnoses & Workup: Cavernous Sinus Thrombosis
Treatment & Medication: Cavernous Sinus Thrombosis
Follow-up: Cavernous Sinus Thrombosis
Multimedia: Cavernous Sinus Thrombosis
References
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References

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Further Reading

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Keywords

cavernous sinus thrombosis, CST, thrombosis of the cavernous intracranial sinus, cavernous sinus syndrome, cavernous sinus, cavernous sinuses, parasellar lesions, tumors, carotid artery aneurysms, carotid-cavernous fistulas, C-C fistulas, cavernous sinus thrombosis

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Contributor Information and Disclosures

Author

Rahul Sharma, MD, MBA, Instructor in Medicine, Weill Medical College of Cornell University; Consulting Staff, Department of Emergency Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center
Rahul Sharma, MD, MBA is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Edward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University
Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

David FM Brown, MD, Assistant Professor, Department of Medicine, Division of Emergency Medicine, Harvard Medical School; Associate-Chief, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

J Stephen Huff, MD, Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Program Director, Professor, Department of Emergency Medicine, Professor, Internal Medicine, University Hospitals, Case Western Reserve School of Medicine
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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